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The “D” refers to six levels of development that define the Carpente, Elefant, & Kim, 2015; Holck, 2004a; Kim, Wigram,
child’s fundamental capacities for 1) shared attention and self- & Gold, 2008; Nordoff & Robbins, 2007). Child-led IMT may
regulation, 2) relatedness and engagement, 3) two-way pur- be viewed as a developmental approach noted for providing
poseful communication, 4) shared problem-solving, 5) sym- a meaningful framework, similar to early mother-infant inter-
bolic thinking, and 6) bridging ideas. According to Greenspan action, which is used to promote shared focus of attention,
(1992), these capacities are the building blocks and founda- turn-taking, and emotional attunement (Holck, 2004b; Kim,
tion for higher levels of thinking and relating such as the ability Wigram, & Gold, 2008). When working within a child-led
to sustain long chains of communication in a back-and-forth framework, the therapist may improvise music that generally
purposeful manner, create and share ideas, and think symboli- follows the child’s focus of attention and interests in order to
cally and abstractly. Table 1 illustrates the six developmental establish a relationship while fostering engagement, related-
levels of social-emotional functioning. ness, and communication (Alvin & Warwick, 1991; Carpente,
The “I” represents Individual differences and refers to how 2013; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015;
the child processes information such as receptive and expres- Holck, 2004b; Kim, Wigram, & Gold, 2008; Nordoff &
sive language, motor and sensory stimuli (e.g., touch, sound, Robbins, 2007). The process of tuning into the child’s musi-
and other sensations), auditory input, visual-spatial informa- cal and non-musical expression has been an integral feature
tion; and motor-planning and sequencing abilities. For each of of clinical practice and is an essential skill of an improvisa-
Developmental Chronological
milestones age Description At risk for ASD
Level I: Shared attention and regulation Occurs 0–3 months of age Internal emotional regulation and homeostasis. An infant at risk for ASD may exhibit challenges
Integrates and utilizes sensory stimuli, i.e., sight, in sustaining attention to sensory stimulation, e.g.,
smell, sound, touch, and taste to self-regulate; sights or sounds, and may prefer to engage in
maintain availability for interaction while perseverative behaviors.
stabilizing awareness of sensations to remain calm
and alert
Level II: Attachment and engagement in Occurs 2–5 months Forming a special relationship with a parent An infant at risk for ASD may display challenges
relationship or caregiver; builds a foundation for future in maintaining engagement, and may withdraw
relationships from interaction and become self-absorbed.
Level III: Two-way purposeful Occurs 4–10 months Purposeful and meaningful communication An infant at risk for ASD may display a lack of
communication using gestures, vocalizations, facial expressions interest in others, or engage in brief back-and-
in order to open and close 5 or more circles of forth exchanges with very little initiative, and may
communication (pre-verbal communication, engage in random behaviors.
reading and processing gestural cues)
Level IV: Behavioral organization, Occurs 10–18 months Developing a complex sense of self. Engages A child at risk for ASD will exhibit challenges
problem-solving, and internalization in a continuous flow of back-and-forth in initiating and sustaining back-and-forth
interactions; engaging is shared problem-solving interactions of emotional signals (e.g., showing
while opening and closing at least 10 or more mom or dad a toy) and may engage in
circles of communication; experiencing and perseverative behavior patterns.
comprehending range of emotions, e.g., pleasure,
assertiveness, curiosity, intimacy, fear, anger
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder
Level V: Representation capacities Occurs 18–30 months of age Internal representation (symbolic thinking). Learns A child at risk for ASD will display challenges
to represent events, things, feelings symbolically; using words and/or phrases meaningfully and
engage in pretend (symbolic) play; functional engaging in pretend play; he/she may repeat
speech continues to develop words (echolalia).
Level VI: Representation differentiation Occurs 30–42 months Bridges between ideas and feelings and connects A child at risk for ASD will engage in memorized
ideas scripts with random ideas; or use words and ideas
Logically; developing abstract thinking and able out of context.
to answer questions dealing with what, when,
how, and why questions
*All information within this table is from Greenspan & Wieder (2006a, 2006b).
3
Table 2.
Six Steps to Administering Floortime™
2010; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Ingersoll, (IMT) intervention in addressing individual social communi-
2008, Wetherby & Woods, 2006). Results indicated significant cation skills of children with ASD. The guiding research ques-
improvement in the children’s ability to share attention, and tion was: Do children with ASD receiving DIR-based IMT
engage with parents and communicate reciprocally after seven improve their social communication functioning, as assessed
months to one year of monthly three-hour parent training visits by the Functional Emotional Assessment Scale (FEAS)?
to the home, and six to ten twenty-minute caregiver-mediated
Floortime sessions at home (Pajareya & Nopmaneejumruslers, Method
2012, Casenhiser, Shanker, & Stieben, 2013; Solomon, Van
Egeren, Mahoney, Huber, & Zimmerman, 2014). Participants
IMT is typically delivered by a highly skilled music therapist in Four participants enrolled in a therapeutic day-school were
a clinical setting. The two RCTs that have assessed the effective- selected by the school psychologist for participation in the study
ness of IMT for children with ASD have found improvements in based on the following criteria: 1) a diagnosis of ASD, 2) newly
joint attention and affective sharing after delivering 30–45-min- enrolled at the therapeutic day-school, 3) 4–8 years of age, and
ute IMT sessions once a week for 12 to 16 weeks (Kim, Wigram, 3) no prior experience in music therapy. Each parent of the
& Gold, 2008; Gattino et al., 2011). While caregiver interven- participants was asked to sign a consent form for their child’s
tions are now considered evidence-based (Wheeler, Williams, participation in the study. All personal information and data
Seida, & Ospina, 2008; Wong et al., 2015) music therapy, was kept strictly confidential (pseudonyms are used throughout
including IMT is regarded as promising but not sufficiently evi- this paper to identify the subjects). The study was reviewed and
denced for improving social interaction in children with ASD approved by an East Coast University and the therapeutic day-
(Rossignol, 2009). Several randomized control trials suggest school’s Institutional Review Board (IRB).
that IMT as an intervention for young children with ASD can
improve responding to joint attention and some forms of ini- Measure
tiating joint attention (Kim, Wigram, & Gold, 2008), affective The Functional Emotional Assessment Scale (FEAS)
sharing and initiating behavior (Kim, Wigram, & Gold, 2009), (Greenspan, DeGangi, & Wieder, 2001) was used as a pre- and
nonverbal communication skills (Gattino, Riesgo, Longo, Leite, post-test to measure each child’s progress toward social com-
& Faccini, 2011), and the parent–child relationship (Thompson, munication development. The FEAS, a play-based assessment
McKerran, & Gold, 2013; Thompson, 2012; Oldfield, 2001). instrument, is a valid and reliable, age-normed, observational
This study will (1) translate and apply DIRFloortime to IMT instrument that has been used in several DIRFloortime studies
principles as a means for improving core features of ASD (Solomon, Necheles, Ferch, & Bruckman, 2007; Solomon, Van
based on a standardized, criterion-referenced rating scale Egeren, Mahoney, Huber, & Zimmerman, 2014; Liao et al., 2014;
developed to evaluate social communication via play context Dionne & Martini, 2011; Pajareya & Nopmaneejumruslers,
(Functional Emotional Assessment Scale) and (2) examine the 2011, 2012). The FEAS was designed to determine a child’s social
effectiveness of a DIR-based improvisational music therapy communication capacities based on the six developmental
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder 5
milestones listed in Table 1. The FEAS includes six subtests that stages to achieve each phase, always beginning and reverting
relate directly to Greenspan’s six functional developmental back to following the client’s musical–emotional lead (Phase 1).
levels and the ages at which typically developing children are IMT was employed within the context of a child-led DIR-based
expected to attain them (Greenspan, DeGangi, & Wieder, 2001): approach. Thus, the therapist created music based on the child’s
1) self-regulation and in shared attention (0–3 months); 2) attach- musical responses, and/or movements, and/or emotionality, and
ment and engagement (2–5 months); 3) two-way, purposeful inclinations or tendencies to foster engagement, relatedness,
communication (10–12 months); 4) behavioral organization and attunement, and social communication. The music therapist cre-
problem-solving (18–30 months); representational capacities ated music that met and followed the child’s musical–emotional
(create ideas, use words or phrases meaningfully, engage in pre- lead in order to foster engagement, relatedness, social interac-
tend play, and think symbolically [18–30 months]); and (6) rep- tion, and communication. The clinically improvised music was
resentational differentiation (build bridges between ideas, think based on the child’s reactions, responses, and emotional state
logically and sequentially, answer “why” questions, thinking as a means to join the child’s play and foster relationship and
abstractly, that is, representation differentiation (30–42 months). shared attention. Hence, the task of the therapist was to pro-
The FEAS scoring system is based on a three-point scale for vide music that deepened the child’s experience in play and fos-
each of six levels of emotional capacity. Items are rated as 0– tered a continuous flow of affective back-and-forth interactions
not at all or very brief; 1–present some of the time, observed though a range of musical contexts and frameworks. The course
Table 3.
Musical–Clinical Intervention Procedural Phases
Data Analysis
The FEAS pre- and post-test ratings for each child were
summed to obtain subtest scores that were totaled to obtain
the total score and compared to the cutoff scores to classify the
child as either “deficient,” “at risk,” or “normal” (Greenspan,
DeGangi, & Wieder, 2001) (see Figure 1). Pre- and post-sub-
test classification levels at pre- and post-test were compared Figure 1. Percentage of children who advanced at least one
for each child in order to assess progress on overall social classification level on the FEAS. * 50% of the children scored
communication and developmental capacities. “normal” at pre-test in area IV and maintained a score of
“normal” at pre-test Thus, all of children (100%) scored “nor-
Results mal” at post-test in level IV.
A comparison of pre- and post-test classification levels on
the FEAS will be presented followed by a description of the
client process and therapist method for each of the four cases for each developmental area in the form of raw scores and
and an integration of the quantitative and qualitative data. subscores, level of functioning, and number of functioning
levels changed (see tables 4–7).
FEAS Scores All participants (100%) were classified as “deficient” on
Comparisons of pre- and post-test scores on the FEAS for overall social communication scores at pre-test. At post-test,
each case (see Figures 2–5) will be discussed in terms of clas- two of the four (50%) advanced two classification levels from
sification (i.e., “deficient,” “at risk,” or “normal”) according to “deficient” to “normal.”
cutoff scores (see Table 8) and clinical descriptions. Figure 1 At pretest all four (100%) participants were scored as “deficient”
illustrates a comparison of the four participants pre- and post- on four of the six subscales: attachment and engagement (level II),
test scores on the FEAS. Each participant’s score is displayed two-way purposeful communication (level III), representational
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder 7
Changes in Developmental Levels illustrates the percentage of children who advanced at least one
Pre Post
classification level on the FEAS. (Note that at pre-test two chil-
2
dren [50%] scored “normal” on behavioral organization [level
IV] and maintained this score following treatment. Therefore, at
L
e 1
post-test all children scored “normal” on level IV.)
v
e
l 0 Case Studies
s
Case 1: Kyle
Area I Area Area III Area IV Area V Area Kyle was deficient in all developmental areas at pre-test
Figure 2. Kyle’s changes in developmental levels. and made no functional progress on any of the areas except
for behavioral organization and problem-solving (level IV),
Changes in Developmental Levels in which he advanced two levels to “normal.” See Table 4
Pr Post for Kyle’s pre- and post-test raw scores and changes in
2
functioning level.
Generally, during Kyle’s first six treatment sessions, he
Table 4.
Comparison of Kyle’s Pre- and Post-FEAS Scores
Pre-test Post-test
Change
Raw scores Raw scores
in functioning
Areas Subscores Subscores level
I. Self-regulation 8 (Deficient) 7 (Deficient) 0
Attentive to play with toys 2 2
Explores objects/toys freely 2 2
Remains calm during play 2 0
Touching textured toys/caregiver 2 2
Shows content affect 1 1
Focused without distraction 0 1
Appears over aroused 0 0
II. Forming relationships 6 (Deficient) 7 (Deficient) 0
made it difficult for him to engage (level II) in continuous two- Case 2: Elaine
way purposeful communication (level III). His ability to adapt Elaine’s pre-test FEAS scores indicated “normal” on behav-
to musical experience in the areas of joining into play interac- ioral organization and problem-solving (level IV), “at risk” on
tions, turn-taking, and imitation appeared to be reflected in self-regulation and shared attention (level I), and “deficient”
his gains in level IV of the FEAS (behavioral organization and in all other developmental areas, that is, engagement, two-
problem-solving). Figure 2 illustrates Kyle’s changes in devel- way purposeful communication, representational capacities,
opmental levels. and representation differentiation. Following treatment, Elaine
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder 9
Table 5.
Comparison of Elaine’s Pre- and Post-FEAS Scores
Pre-test Post-test
Change
Raw scores Raw scores
in functioning
Areas Subscores Subscores level
I. Self-regulation 11 (At risk) 12 (Normal) +1
Attentive to play with toys 2 2
Explores objects/toys freely 2 2
Remains calm during play 2 2
Touching textured toys/caregiver 2 2
Shows content affect 1 1
Focused without distraction 1 2
Appears over aroused 1 1
II. Forming relationships 11 (Deficient) 16 (Normal) +2
had advanced to “normal” on all developmental areas except she appeared to become easily dysregulated and unengaged
for representational (level V), in which she improved to “at- while moving and displayed difficulty self-regulating. When
risk.” See Table 5 for Elaine’s pre- and post-test raw scores and engaged in instrument play, she exhibited challenges main-
changes in functioning level. taining engagement and relatedness, as well as difficulty
Treatment sessions 1 through 5 included Elaine craving adapting to dynamic and tempo changes.
motion as she moved aimlessly around the music room while Sessions 6 through 10 consisted of the therapist attempt-
playing each instrument in an unrelated manner. Generally, ing to guide Elaine’s perseverative movements into interactive
10 Music Therapy Perspectives
Table 6.
Comparison of Anthony’s Pre- and Post-FEAS Scores
Pre-test Post-test
Change
Raw scores Raw scores
in functioning
Areas Subscores Subscores level
I. Self-regulation 10 (Deficient) 13 (Normal) +2
Attentive to play with toys 2 2
Explores objects/toys freely 2 2
Remains calm during play 2 2
Touching textured toys/caregiver 0 2
Shows content affect 1 1
Focused without distraction 2 2
Appears withdrawn/sluggish 1 2
II. Forming relationships 12 (Deficient) 16 (Normal) +2
dance experiences, following her lead of movement in order periods during musical play. This was evident by her ability
to foster self-regulation, engagement, and relatedness. Her to sustain musical interaction via instrument play and move-
dance-like interactions were generally accompanied by the ment to the waltz-like music being presented. When engaged
therapist providing legato and lyrical singing, playing the in instrument play, she demonstrated the ability to interact
piano in ¾ tempo, and incorporating words that Elaine offered in a related manner on the drum and cymbal by playing the
via her repetitive and echolalic vocalizations. basic beat and engaging in call-and-response play, punctuat-
During sessions 11 through 15, Elaine demonstrated a sig- ing ends of phrases on the cymbal. In addition, while engaged
nificant increase in her ability to self-regulate for extended in these robust musical interactions, Elaine exhibited affective
Music Therapy Program on Social Communication for Children with Autism Spectrum Disorder 11
Table 7.
Comparison of Michele’s Pre- and Post-FEAS Scores
Pre-test Post-test
Change
Raw scores Raw scores
in functioning
Areas Subscores Subscores level
I. Self-regulation 11 (At risk) 13 (Normal) +1
Attentive to play with toys 2 2
Explores objects/toys freely 2 2
Remains calm during play 2 2
Touching textured toys/caregiver 2 2
Shows content affect 1 2
Focused without distraction 1 2
Appears over aroused 1 1
II. Forming relationships 6 (Deficient) 16 (Normal) +2
extra-musical responses such as smiling and socially referenc- the music while implementing musical spaces and exaggera-
ing the therapist with eye glances and nonverbal vocalizations. tion of Elaine’s responses in order to foster two-way purposeful
Her challenges related to postural control and motor plan- play and reciprocal interactions (treatment phase 2).
ning made it difficult for her to sustain a continuous flow Musical styles and frameworks, such as flamenco and Latin,
of basic beating; however, she maintained engagement and were used during instrument play because of their boldness,
relatedness through facial expressions and social referencing. clarity of tempo, rhythmic nature (included syncopation), and
The therapist incorporated these extra musical responses into emphasis on a strong downbeat. These musical interventions
12 Music Therapy Perspectives
offering song ideas. To that end, he engaged in higher levels back-and-forth musical pauses. Her ability to maintain self-
of musical interaction such initiating and assimilating and dif- regulation and engage via a range of musical experiences
ferentiating musical ideas, via a range of affect and musical had expanded. In addition, because of the increase in atten-
expressivity. These capacities seemed to be indicated in his tion and engagement, Michele’s ability to engage in two-
post-test FEAS scores by advances from “deficient” to “nor- way purposeful musical play had emerged. These capaci-
mal” in all areas. Figure 4 illustrates Anthony’s changes in ties demonstrated in musical play appeared to be reflected
developmental levels. in her improved FEAS post-test scores. Her FEAS scores
indicated “normal” on self-regulation (level I), engagement
Case 4: Michele (level II), and behavior organization (level IV). In addition,
At pretest, Michele scored “deficient” on all developmental she improved to “at-risk” in the areas of two-way purpose-
areas except for self- regulation (level I), in which she scored ful communication (level III). Figure 5 illustrates Michele’s
“at-risk.” Following treatment, her post-test indicated “nor- changes in developmental levels.
mal” on self-regulation (level I), engagement (level II), and
behavioral organization (level IV). She scored “at-risk” on Discussion
two-way purposeful communication (level II) and maintained The results of this case series of DIR-based IMT are con-
a score of “deficient” on representational differentiation (level sistent with evidence from other IMT studies showing its
monthly home visits to train parents as well as a minimum 2007; Geretsegger, Holck, Carpente, Elefant, & Kim, 2015;
of two hours a day of parent-mediated treatment (Solomon, Kim, Wigram, & Gold, 2008, 2009; Thompson, McFerran, &
Necheles, Ferch, & Bruckman, 2007; Solomon, Van Egeren, Gold, 2013).
Mahoney, Huber, & Zimmerman, 2014; Dionne & Martini,
2011; Liao et al., 2014). Whether IMT offers advantages for
improving social communication in children with ASD is a References
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